First Name: Last Name: Middle Initial:
Phone: Cell: Email:
DOB: Social security number:
Sex: MaleFemale Marital Status:SingleMarriedWidowedDivorced
City: State: Zip:
Employer: Employer’s Phone: Are you self-employed? Yes No
If patient is a minor :
In case of Emergency please notify: Father Name: Phone:
Mother Name: Phone: Others: Phone:
Primary Insurance: ID# Group/Policy#
Insured Name: Insured DOB: Relationship to Patient:
Insured social security #: Insured Address:
Secondary Insurance: ID# Group/Policy#
Insured social security #: Insured Address (if different from above)
Tertiary Insurance: ID# Group/Policy#
Primary Doctor’s Name: Phone: Referred by:
Pharmacy Name: Phone:
I authorize Dr. Maher N. Nashed to treat the above-named patient.
I authorize the use of this form for all my insurance submissions.
It is my responsibility to immediately notify the staff of any insurance changes.
I authorize the release of information from all my insurance companies.
I authorize my doctors to act as my agent in helping me obtain payments from my insurance companies.
I authorize direct payment to Dr. Maher N. Nashed.
I understand that I am responsible to obtain referrals from my PCP.
If no referrals are provided, I understand that I am responsible for payment for services rendered by Dr. Maher N. Nashed.
I understand that I am responsible for payments for services rendered by Dr. Maher N. Nashed.
I permit a copy of this authorization to be used in place of the original.
By putting your name in the box below, you agree with all the above terms as if you are signing in person.
PATIENT’S NAME: Date:
PATIENT UNDER 18- LEGAL GUARDIAN Name: Date: